Pathways of care of women in secure hospitals: which women go where and why.

BACKGROUND: Care pathways for women needing expensive, secure hospital care are poorly understood. AIMS: To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type. METHOD: Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fisher's exact tests for categorical data. Thematic analysis was used for free text data. RESULTS: The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone. CONCLUSIONS: Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

The reliability and validity of the forensic Camberwell Assessment of Need (CANFOR): a needs assessment for forensic mental health service users.

No instrument exists that measures the individual needs of forensic mental health service users (FMHSUs). The aim of this study was therefore to develop a valid and reliable individual needs assessment instrument for FMHSUs that incorporated staff and service user views and measured met and unmet needs. The Camberwell Assessment of Need was used as a template to develop CANFOR. Consensual and content validity were investigated with 50 forensic mental health professionals and 60 FMHSUs. Both were found to be satisfactory. Concurrent validity was tested using the Global Assessment of Functioning and a five-point needs scale, and again was found to be satisfactory. Reliability studies were carried out with 77 service users and 65 staff in high and medium security psychiatric services in the UK. Inter-rater reliability, rating whether a need was present or not, was high for service users (0.991) and staff (0.998). Similarly high reliability was found for unmet needs (0.985 and 0.972, respectively). Test-retest reliability was found to be moderately high for service users (0.795) and staff (0.852) when ratings were made two weeks apart. Similar levels were found for ratings of unmet needs (0.813 and 0.699, respectively). The average interview time was 23 minutes. CANFOR has good validity and reliability, and is suitable for further testing with other service user groups.

Ethnic differences among patients in high-security psychiatric hospitals in England.

BACKGROUND: Black (Black Caribbean and Black African) patients are over-represented in admissions to general adult and medium-security psychiatric services in England. AIMS: To describe the sociodemographic, clinical and offence characteristics of patients in high-security psychiatric hospitals (HSPHs) in England, and to compare admission rates and unmet needs by ethnic group. METHOD: A total of 1255 in-patients were interviewed, and their legal status, socio-demographic characteristics and individual treatment needs were assessed. RESULTS: Black patients in HSPHs are over-represented by 8.2 times (range 3.2-24.4,95% CI 7.1-9.3), are more often male (P=0.037), and are more often diagnosed with a mental illness and less often diagnosed with a personality disorder or learning disability (P<0.001) than White patients. Unmet needs were significantly less common among White than among Black patients (mean values of 2.22 v. 2.62, difference=0.40,95% CI 0.06-0.73). CONCLUSIONS: Compared with the proportion of Black patients in the general population in their region of origin, a much higher proportion of Black patients were admitted to HSPHs, and fewer of their needs were met.